How is gastroesophageal reflux disease in children treated?

Treatment for gastroesophageal reflux disease consists of 3 components:

1. a complex of non-drug interventions, primarily normalization of lifestyle, daily routine and nutrition;
2. conservative therapy;
3. surgical correction.

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Treatment of gastroesophageal reflux disease in young children

According to the ESPGHAN recommendations (2005), treatment of regurgitation consists of several successive stages.

• Postural therapy (positional treatment): the baby should be fed in a sitting position, held at an angle of 45-60°. After feeding, the position should be maintained for at least 20-30 minutes, then the baby can be laid on his back, raising the head end by 30°.
• Dietary correction: increase the number of feedings, reducing the single volume of food. When breastfeeding, use breast milk thickeners (Bio-Rice Broth mixture, HIPP). Children over 2 months old can be given denser food before feeding (1 teaspoon of milk-free rice porridge). For children on artificial feeding, mixtures with thickeners containing gum (carob bean gluten), for example, Nutrilon AR, Frisovom, Humana AR, Nutrilak AR, or rice starch (amylopectin), for example, Semper-Lemolak, Enfamil AR, are recommended.
• Prokinetic agents: domperidone (motilium, motilak) 1-2 mg/kg per day in 3 doses or metoclopramide (cerucal) 1 mg/kg per day in 3 doses 30 minutes before meals for 2-3 weeks.
• Antacids (for stage I esophagitis): phosphalugel 1/4-1/2 sachet 4-6 times a day between feedings for 3-4 weeks.
• Antisecretory drugs (for grade II-III esophagitis): proton pump inhibitors - omeprazole (Losec) 1 mg/kg per day once a day 30-40 minutes before feeding for 3-4 weeks. Data from foreign multicenter studies prove the safety of proton pump inhibitors when prescribed to young children; ESPGHAN allows recommending omeprazole to children from 6 months of age.

Treatment of gastroesophageal reflux disease in older children

Correction of the child's lifestyle plays an important role in treatment.

• Raising the head of the bed by at least 15 cm. This measure reduces the duration of esophageal acidification.
• Introduction of dietary restrictions:
  • reducing the fat content in the diet (cream, butter, fatty fish, pork, goose, duck, lamb, cakes), since fats reduce the tone of the lower esophageal sphincter;
  • increasing the protein content in the diet, since proteins increase the tone of the lower esophageal sphincter;
  • reduction in food volume;
  • limiting irritating foods (citrus juices, tomatoes, coffee, tea, chocolate, mint, onions, garlic, alcohol, etc.) to prevent direct damaging effects on the esophageal mucosa and reducing the tone of the lower esophageal sphincter.
• Weight loss (if obese) to eliminate the suspected cause of reflux.
• Developing the habit of not eating before bed, not lying down after eating to reduce the volume of gastric contents in a horizontal position.
• Eliminate tight clothing and tight belts to avoid increased intra-abdominal pressure, which increases reflux.
• Avoid deep bends, prolonged stay in a bent position (the “gardener” pose), lifting weights over 8-10 kg in both hands, and physical exercises associated with overstraining the abdominal muscles.
• Limit the intake of medications that reduce the tone of the lower esophageal sphincter or slow down esophageal peristalsis (sedatives, hypnotics, tranquilizers, calcium channel blockers, theophylline, anticholinergics).
• Elimination of smoking, which significantly reduces the pressure of the lower esophageal sphincter.

Drug treatment of gastroesophageal reflux disease in children

Gastroesophageal reflux without esophagitis, endoscopically negative variant, as well as gastroesophageal reflux with reflux esophagitis grade I:

• antacid drugs, mainly in the form of a gel or suspension: aluminum phosphate (phosphalugel), maalox, almagel - 1 dose 3-4 times a day 1 hour after meals and at night for 2-3 weeks. Gaviscon is prescribed orally to children 6-12 years old, 5-10 ml after meals and before bedtime;
• prokinetic agents: domperidone (motilium, motilak) 10 mg 3 times a day, metoclopramide (cerucal) 10 mg 3 times a day 30 minutes before meals for 2-3 weeks;
• symptomatic treatment (for example, respiratory pathology associated with gastroesophageal reflux).

Gastroesophageal reflux with reflux esophagitis grade II:

• antisecretory drugs of the proton pump inhibitor group: omeprazole (Losec, Omez, Gastrozole, Ultop, etc.), rabeprazole (Pariet), esomeprazole (Nexium) 20-40 mg per day 30 minutes before meals for 3-4 weeks;
• prokinetic agents for 2-3 weeks.

Gastroesophageal reflux with reflux esophagitis grade III-IV:

• antisecretory drugs of the proton pump inhibitor group for 4-6 weeks;
• prokinetic agents for 3-4 weeks;
• cytoprotectors: sucralfate (Venter) 0.5-1 g 3-4 times a day 30 minutes before meals for 3-4 weeks.

Taking into account the role of the nervous system (especially the autonomic division) in the pathogenesis of gastroesophageal reflux, signs of autonomic dystonia or CNS pathology, it is indicated to prescribe complex treatment that takes into account all links in the pathogenesis of gastroesophageal reflux disease:

• vasoactive drugs (vinpocetine, cinnarizine);
• nootropic agents (hopantenic acid, piracetam);
• drugs with complex action (instenon, phenibut, glycine, etc.):
• sedatives of plant origin (preparations of motherwort, valerian, hops, St. John's wort, mint, hawthorn).

Example of a basic treatment program:

• phosphalugel - 3 weeks;
• motilium - 3-4 weeks.

It is recommended to repeat the course of treatment with prokinetic agents after 1 month.

The question of the advisability of prescribing antisecretory drugs (histamine H2-receptor blockers _or proton pump inhibitors) is decided individually, taking into account the prevailing clinical symptom complex, the results of the study of the acid-forming function of the stomach (hypersecretory status), daily pH monitoring (pronounced acid gastroesophageal reflux), as well as in case of insufficient effectiveness of the basic treatment program.

Physiotherapy

They use phoresis with sinusoidal modulated currents with cerucal on the epigastric region, decimeter waves on the collar zone, and the Electroson device.

During the period of remission, children are recommended to undergo spa treatment in gastrointestinal institutions.

Surgical treatment of gastroesophageal reflux disease

Fundoplication is usually performed using the Nissen or Thal method. Indications for fundoplication:

• pronounced clinical picture of gastroesophageal reflux disease, significantly reducing the patient's quality of life despite repeated courses of drug antireflux treatment;
• long-term persistent endoscopic symptoms of reflux esophagitis grade III-IV against the background of repeated courses of treatment;
• complications of gastroesophageal reflux disease (bleeding, strictures, Barrett's esophagus);
• combination of gastroesophageal reflux disease with hernia of the esophageal opening of the diaphragm.

Anti-relapse treatment of gastroesophageal reflux disease in children

The use of antacid and prokinetic agents, antisecretory drugs during the period of stable clinical and morphological remission is not indicated, but symptomatic medications can be prescribed to the patient for use “on demand”.

In case of esophagitis of III-IV degree, prolonged administration of proton pump inhibitors (1-3 months) in a maintenance (half) dose is indicated. For anti-relapse purposes, autumn-spring courses of phyto- and vitamin therapy, balneotherapy are indicated.

Children with gastroesophageal reflux disease in the stage of incomplete clinical and endoscopic remission are recommended to take physical education classes in the main group without passing timed standards and without participating in competitions; in the stage of complete clinical and endoscopic remission, classes in the main group are allowed.

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Outpatient observation

The sick child is monitored until he/she is transferred to an adult outpatient clinic by a local pediatrician and a district gastroenterologist. The frequency of examinations depends on the clinical and endoscopic data and is at least twice a year.

The frequency of fibroesophagogastroduodenoscopy is determined individually based on clinical and anamnestic data, the results of previous endoscopic studies and the duration of clinical remission.

• In the case of endoscopically negative gastroesophageal reflux disease and grade I reflux esophagitis, the study is indicated only in the case of an exacerbation of the disease or when transferring to the adult network.
• In case of gastroesophageal reflux disease and/or reflux esophagitis grade II-III, fibroesophagogastroduodenoscopy is performed once a year or during an exacerbation of the disease, as well as when transferring to an adult network.
• In gastroesophageal reflux disease with grade IV reflux esophagitis (esophageal ulcer, Barrett's esophagus), the study is performed every 6 months in the first year of observation and every year thereafter (subject to clinical remission of the disease).

A study of the secretory function of the stomach (pH-metry) is performed no more than once every 2-3 years. The need and timing of repeated daily pH-monitoring are determined individually.

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